Gingivitis

Basics

Description

  • Gingivitis and periodontitis are both classified under periodontal disease.
    • Gingivitis is inflammation limited to the gingiva and not resulting in periodontal ligament (PDL) attachment and bone loss.
    • Periodontitis is inflammation of the gingiva and adjacent connective tissue attachment, characterized by loss of PDL, connective tissue, and alveolar bone.
  • Gingivitis can be localized to a limited area or generalized, involving the entire gingiva.
  • Depending on etiology, gingivitis can also present as acute or chronic.

Epidemiology

  • Gingivitis occurs in 50% of children with mild, marginal gingivitis being the most common form.
  • Severe gingivitis is relatively uncommon in healthy children.
  • The prevalence of gingivitis increases with age, with a peak at puberty, likely due to hormonal influences and inconsistent oral hygiene.

Risk Factors

  • General risk factors
    • Increased dental plaque formation—inconsistent brushing and flossing, frequent carbohydrate intake
    • Local areas of plaque accumulation—erupting teeth, crowded teeth, orthodontic appliances/bands/brackets, poor brushing technique.
    • Decreased saliva (self-cleaning effect) leading to dry mouth/xerostomia—mouth breathing, many pediatric medications
    • Increase gingival inflammatory response— immunodeficient conditions, chronic illnesses, certain medications
  • Specific risk factors
    • Medications: antiepileptics, cyclosporine, calcium channel blockers
    • Hormonal changes: puberty, pregnancy
    • Immunologic deficiencies: HIV, Chédiak-Higashi, cyclic neutropenia
    • Chronic illnesses: diabetes mellitus, chronic renal failure, histiocytosis X, scleroderma, secondary hyperparathyroidism
    • Neurologic problems: developmental delay, cerebral palsy, other conditions where oral hygiene is difficult
    • Behavioral factors: smoking, stress, alcohol consumption
    • Miscellaneous: malnutrition, viral illnesses

General Prevention

  • Prevention of gingivitis is directed toward effective removal of dental plaque on a daily basis:
    • Infants: washcloth to remove plaque after feeding; toothbrush using baby toothpaste (nonfluoridated)
    • Children: assistance with brushing with a small amount of toothpaste after meals.
    • Older children and adolescents: Brush teeth after meals with fluoridated toothpaste in addition to daily flossing.
    • Children/adolescents with high-risk factors must brush and floss consistently.
  • The American Academy of Pediatrics (AAP) recommends that children at high risk for dental caries should establish routine dental care by their first birthday. Children should then continue routine dental checkups at a minimum of every 6 months.

Etiology

  • Gingivitis most often occurs in response to bacterial biofilm/plaque at the gingival margin (gingiva covering the necks of the teeth).
  • Accumulation of dental bacterial plaque is a direct cause of gingival inflammation. Plaque accumulation can be caused by:
    • Inconsistent brushing and flossing
    • Local areas that are difficult to access and clean
    • Decreased saliva/xerostomia
  • Increased gingival inflammatory response
    • Normal/abnormal hormone fluctuations
    • Alterations in insulin levels in patients with diabetes
    • Vitamin deficiencies (e.g., vitamin C deficiency)
  • Infectious diseases leading to gingival inflammation/ulceration
    • Herpes simplex virus (HSV) type I
    • Candida albicans
    • HIV
  • Medications promoting gingival overgrowth
    • Phenytoin
    • Cyclosporine
    • Nifedipine
    • Oral contraceptive pills
  • Trauma

Diagnosis

History

  • Assess medical history for chronic illnesses, bleeding disorders, immunodeficiencies, etc.
  • Assess home oral hygiene practice, focusing on brushing/flossing frequency. Review hygiene technique if practical.
  • Assess the diet, including carbohydrate intake/frequency, and possible nutritional deficiencies.
  • Review medications, taking note of any that may increase risk of gingival inflammation/enlargement.
  • Review any intraoral complaints:
    • Bleeding gums on brushing or spontaneously
    • Gingival pain on brushing, eating, or spontaneous
    • Gingival swelling
    • Review when symptoms arose, how often, etc.

Physical Exam

  • Mild signs are usually gingival erythema and bleeding with brushing or flossing.
  • Moderate to severe signs include swelling, ulceration, and tenderness.
  • Examine the head and neck for signs of swelling, erythema, warmth, enlarged maxillary lymph nodes, as well as right/left symmetry.
  • Examine the gingival tissue for erythema, swelling, ulceration, fluctuance, or drainage.
  • Assess whether gingival inflammation is localized to an area (local factor) or generalized, involving the entire upper and lower gingiva (systemic factor/medication).
  • Assess for pain or sensitivity on palpation.
  • Assess oral hygiene, noting plaque buildup, crowding, carious teeth, abscesses.
  • Take note of any orthodontic appliances that may decrease effectiveness of brushing and flossing.
  • Evaluate the teeth for caries, fractures, looseness, malocclusion, pain, and plaque.

Differential Diagnosis

  • Localized gingivitis
    • Poor hygiene technique: Check routine.
    • Food impaction: Check diet.
    • Orthodontic appliances
    • Pregnancy tumor (pyogenic granuloma)
    • Abscess: Check for caries.
    • Trauma: Check history.
    • Self-inflicted injury—unusual location and history
  • Generalized gingivitis—healthy presentation
    • Extremely poor or no oral hygiene
    • Diet high in carbohydrates
  • Generalized gingivitis—systemic manifestations
    • Herpetic gingivostomatitis—fever; malaise
    • Neutrophil disorders
    • Leukemia
    • HIV
    • Graft-versus-host disease (infiltrative gingivitis)
    • Vitamin C deficiency
    • Behçet disease
  • Generalized gingivitis—bleeding
    • Hemophilia (factor VIII or IX deficiency)
    • Thrombocytopenia
  • Generalized gingivitis—overgrowth
    • Gingival hyperplasia due to medication
    • Gingival hyperplasia due to hormone fluctuation
  • Generalized gingivitis—severe, rapid
    • Acute necrotizing ulcerative gingivitis (ANUG)—painful gingivitis associated with rapid onset and tissue ulceration and necrosis
      • Peaks in adolescence and young adulthood
      • Related to high oral concentrations of spirochetes and/or Prevotella intermedia

Diagnostic Tests and Interpretation

Initial Tests

  • Most patients do not need laboratory evaluation to assess causes of gingivitis. Biopsy may be necessary to confirm or narrow differential diagnoses but is usually performed by a periodontist or oral surgeon.
  • If there is a concern for excessive bleeding, a CBC with differential, PT, and PTT may be helpful to rule out thrombocytopenia, pancytopenia, or a clotting disorder.
  • If there is concern for sepsis, blood culture may be necessary.
  • Direct fluorescent antibody testing for HSV-1: If herpes is suspected (stomatitis is usually present), swab the base of a stoma/vesicle and smear on a slide. HSV culture is the gold standard.
  • Panoramic or intraoral radiographic imaging by a pediatric dentist may be necessary to assess severity of inflammation and possible loss of alveolar bone.

Treatment

General Measures

  • A consistent oral hygiene regime directed at minimizing plaque buildup is essential to prevent or manage gingivitis.
    • Brushing after breakfast and prior to bedtime allows for consistent clearance of food and keeps plaque manageable.
    • Mechanical/sonic toothbrushes allow for more effective plaque removal.
    • Toothpaste with fluoride when child can expectorate
    • Flossing if teeth are in tight contact and not spaced apart
    • Regular visits to a pediatric dentist for examination and thorough cleaning/scaling every 4 to 6 months
  • For moderate to severe gingivitis, possible risk factors should be assessed and additional measures implemented.
    • Mouth rinses for plaque inhibition using 0.12% chlorhexidine gluconate oral rinse
    • More frequent dental visits for reassessment and thorough cleanings/scalings
    • Gingivectomy to allow for more access to plaque
    • Antibiotics to cover mouth flora in more severe cases when bacterial superinfection is suspected.

Medication (Drugs)

  • Mouth rinses for plaque inhibition are prescribed when daily oral hygiene is insufficient to control plaque.
    • The most commonly used rinse is 0.12% chlorhexidine gluconate oral rinse.
    • Chlorhexidine gluconate is prescribed as a temporary measure in children to stabilize inflammation as the source of inflammation is controlled.
  • Antibiotics are rarely prescribed for mild or moderate gingivitis.

Issue for Referral

  • It is important for providers to evaluate the oral health of all children. When gingival inflammation is noted, the patient should be referred to a pediatric dentist for assessment and management.
  • For severe cases of gingivitis, a periodontist should be consulted to provide timely assessment and aggressive management. The pediatric dentist may consult after first assessment.
  • Generalized cases of gingivitis may need referral to a pediatric specialist to assess for systemic causes or medications that may be manifesting orally.

Diagnostic Procedures/Other

In cases of gingival hypertrophy, localized or generalized gingivectomy by a periodontist may be necessary to remove excess gingival tissue, allowing for more effective plaque access and removal.

Ongoing Care

Follow-Up Recommendations

  • Regular dental visits for professional cleanings and plaque removal is recommended for all children and adults.
  • Children with moderate to severe gingivitis will need more frequent dental visits until gingivitis is controlled; most dentists recommend every 3 months.

Patient Monitoring

  • Children with moderate to severe gingivitis will need more frequent dental visits to assess extent of inflammation and modify office/home management until gingivitis is under control.
  • Periodic intraoral radiographs may be necessary to monitor extent of bone loss.

Diet

  • Minimize amount and frequency of high–sugar content food and beverages.
  • Xylitol-containing chewing gum can improve oral hygiene by reducing plaque adherence to the gum line.

Patient Teaching

  • Establish a daily oral hygiene routine involving a moderate diet, brushing, and flossing.
  • Brushing after breakfast and prior to bedtime allows for consistent clearance of food and keeps plaque manageable.
  • Mechanical/sonic toothbrushes allow for more effective plaque removal.
  • Toothpaste with fluoride when child can expectorate
  • Flossing if teeth are in tight contact and not spaced apart
  • Regular visits to a pediatric dentist reassessment and thorough cleaning/scaling every 4 to 6 months

Prognosis

  • Timely assessment, management, and consistent home oral hygiene may reverse mild to moderate gingivitis within several months.
  • Periodontal disease may not be reversible; therefore, prevention is essential.

Complications

  • Pain leading to detrimental changes in hygiene, diet, behavior, and daily routine
  • Irreversible periodontitis
  • Premature tooth loss
  • Osteomyelitis
  • Subacute bacterial endocarditis (SBE)

Additional Reading

  1. American Academy of Pediatric Dentistry. Guideline on periodicity of examination, preventive dental services, anticipatory guidance, and oral treatment for children, and adolescents. http://www.aapd.org/media/Policies_Guidelines/G_Periodicity7.pdf. Accessed May 19, 2017.
  2. American Academy of Pediatric Dentistry. Endorsement. Periodontal diseases of children and adolescents. http://www.aapd.org/media/Policies_Guidelines/E_PeriodontalDisease1.pdf. Accessed May 19, 2017.
  3. American Academy of Pediatric Dentistry. Endorsement. Guideline for periodontal therapy. http://www.aapd.org/media/Policies_Guidelines/E_PerioTherapy1.pdf. Accessed May 19, 2017.
  4. American Academy of Pediatric Dentistry. Endorsement. Treatment of plaque-induced gingivitis, chronic periodontitis, and other clinical conditions. http://www.aapd.org/media/Policies_Guidelines/E_Plaque1.pdf. Accessed May 19, 2017.

Codes

ICD-9

  • 523.10 Chronic gingivitis, plaque induced
  • 523.00 Acute gingivitis, plaque induced
  • 101.0000 Vincent’s angina

ICD-10

  • K05.10 Chronic gingivitis, plaque induced
  • K05.00 Acute gingivitis, plaque induced
  • A69.1 Other Vincent’s infections

SNOMED

  • 66383009 Gingivitis (disorder)
  • 31642005 Acute gingivitis (disorder)
  • 399050001 Acute necrotizing ulcerative gingivitis (disorder)

FAQ

  • Q: Are there differences among toothpastes and prevention of gingivitis?
  • A: Yes. A stabilized stannous fluoride toothpaste is effective in preventing gingivitis. When essential oil mouthwashes (e.g., Listerine®) are added, there is additional reduction in the amount of gingivitis noted.
  • Q: What dietary changes may improve gingival health?
  • A: Avoiding frequent carbohydrate intake may reduce gingivitis. Carbonated beverages, sugared chewing gum, and candy often adhere to teeth. When daily dental care is inconsistent, plaque formation is increased and gingivitis is much more likely.
  • Q: Why do children generally not have the significant periodontal disease that adults get?
  • A: No one knows for sure; however, it is known that the gingiva of the primary dentition is rounder and thicker and contains more blood vessels and less connective tissue than the gingival seen later in life. Whether these differences mask disease or are helpful is unclear.
  • Q: How do intraoral piercings impact gum health?
  • A: In addition to fractured teeth, gingival recession and gingivitis are complications of the trauma inflicted by a foreign body in the oral cavity.
  • Q: Why is smoking associated with gingival disease?
  • A: Nicotine inhibits phagocyte and neutrophil function, reduces bone mineralization, impairs vascularization, and reduces antibody production. Smokers do not respond as well as nonsmokers to surgical and nonsurgical treatments.

Authors

Ray J. Jurado, DDS


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